SOAP Carpal Tunnel Syndrome

SOAP Note Patient Information: Name: S, C Age: 34 yo DOB: 03/07/1988 Sex: Female Medical Record Number: 012537 Ethnicity: Caucasian Interview Date and Location: 04/24/2022 1600 – St. Joseph Mercy Ann Arbor Code Status: Full Code Source of Information: Information was obtained from the patient who appeared reliable and A&Ox4. Subjective: CC: CS is a 34-year-old Caucasian female who presented to the outpatient clinic with “right hand numbness and discomfort” for several weeks. HPI: Pt states that she has been experiencing 3-4/10 right hand pain for several weeks. Pain is worst in the right thumb, index, and middle finger. Pt also admits to numbness, tingling, sensation loss, and decrease in muscle strength and size in the right hand. She states the pain is worse at night, using her hands above her head, and while brushing her hair or driving. Pt says the pain and numbness do not radiate, but her right forearm and shoulder sometimes ache at night. She admits to this interfering at her job in the OR as a nurse. Occasionally, she feels the same pain and sensation for short periods of time in her left hand. Pt states that the pain is alleviated by shaking her hand. CS also admits to taking Tylenol over the counter for pain control. CS denies any previous history of similar symptoms. CS denies any other symptoms, including weight loss, blurry vision, joint deformity or swelling, myotonia, gait abnormalities, arthralgias, muscle spasms, fatigue, depression, incontinence, or dry mouth. PMH: 1 live birth Current Medications:  Daily multivitamin PO QD  Tylenol 500mg PO PRN Allergies: NKDA, NKFA FMH:  Mother: Alive, 54 yo, Rheumatoid Arthritis  Father: Deceased at 42yo, Multiple Sclerosis Social Hx:  ETOH: 0-1x week  Marijuana: 2-3x week  Pt denies tobacco or illicit drug use  Weightlifting 4x week (up to 150lb) ROS: General: CS appears in no acute distress. She is awake, alert, and cooperative. Appears to be of stated age and appropriately dressed. Neuro: CS admits to right-handed paresthesia and numbness predominately in the thumb, index, and middle fingers. CS denies gait abnormalities, vision changes, dysarthria, confusion, and mood changes. Musculoskeletal: CS admits to right hand pain, especially at night. Pt admits to weakness and decreased muscle size on right hand. CS denies neck pain, spine pain, chest pain, joint pain, muscle cramps, tetany, recent trauma, and swelling. Objective: Vitals: BP: 105/75 mmHg (LA, sitting) Temp: 37.0ºC (98.6 ºF), oral Pulse: 72 bpm, regular Resp: 15, unlabored Pulse Ox: 98% on room air Ht: 5’7 Wt: 125lbs BMI: 19.6 Musculoskeletal: Clear atrophy and mild fasciculation of the right thenar eminence, no muscle asymmetry. Weakness of right opponens pollicis and abductor pollicis muscles, other muscle groups 5/5. No swelling, enlargement, or tenderness over any hand joint. Finger positions WNL with no clubbing, joint swelling, inflammation, redness, deformities, contractures, or bursitis. No swelling, enlargement, or tenderness over any hand joint. Stretching the ulnar nerve by elbow flexing yields no ulnar paresthesia. Negative Lhermitte’s test. Neurological: Phalen sign shows clear numbness in thumbs, index, and middle fingers on carpal tunnel compression on right hand. Tinel sign produces paresthesia’s in the right thumb index and middle fingers. Loss of two-point discrimination on right hand. Stretching the ulnar nerve by elbow flexing yields no ulnar paresthesia. Negative Spurling test. Negative Chvostek’s sign. Dx: 1. Carpal Tunnel Syndrome a. (ICD: G56.0) 2. Rheumatoid Arthritis 3. Multiple Sclerosis 4. Distal Radius Fracture Assessment: CS is 34 yo Caucasian female who presents to the clinic with several weeks of paresthesias, 34/10 pain, numbness, and weakness in her right hand predominately, with occasional occurrences in the left hand. No joint pain, inflammation, deformities, nodules, and the absence of rheumatoid factor makes the diagnosis of RA unlikely. The negative X-ray results make the diagnosis of a fracture unlikely. The lack of rheumatoid factor, no abnormalities seen on MRI, absence of visual changes or gait abnormalities makes the diagnosis of multiple sclerosis unlikely. Significant history, review of symptoms, physical exam, and positive Tinel’s sign and Phalen sign support the diagnosis of carpal tunnel syndrome. Plan: 1. Diagnostic a. TSH and CBC – r/o underlying conditions i. Lab results WNL b. Pregnancy test i. Results are negative c. Wrist X-ray – r/o fracture i. No abnormalities d. EMG Nerve Conduction test i. Results show mild denervation of the right opponens pollicis muscle and marked slowing of the nerve conduction across the wrist on the right side. Left sided study is normal except for mild slowing of nerve conduction across the left wrist. Prominent slowing of sensory conduction of the median nerves bilaterally, right worse than left. e. Rheumatoid Factor i. Results demonstrated WNL f. MRI of head/spine i. Results demonstrated no abnormalities 2. Treatment a. Night splinting (daytime as tolerated) b. 40mg Methylprednisolone Acetate local injection into right wrist 3. Education a. Educate patient regarding diagnosis, treatment, differentials, and plan of care b. Educate patient about corticosteroid injection and side effects 4. Consults a. Refer to orthopedics for follow up in 6 weeks to monitor symptoms and treatment plan 5. Follow-up a. Return to office or go to ED if symptoms worsen b. Return to office or to orthopedic for follow up in 6 weeks